The UniversalMedical Viewer

Selecting Technologyto Meet Your Needs

INTRODUCTIONCan a medical image management system please all of the people all of the time? Maybe, if it includes a high-quality universal image viewer—particularly one that evolves with the hospital’s changing needs.

Today, the nature of image viewing is changing. The concept of dedicated technology residing on a single workstation and tied to a particular departmental solution is rapidly becoming a part of the past. As the need—and legislative man-date—to share images across departments, multi-site enterprises and entire communities expands, a more flexible vendor neutral viewing system that provides anywhere, anytime image access is rapidly becoming an expectation.

Specifically what is a universal image viewer? To some extent this depends on who you ask and what universe they inhabit. Essentially, a universal viewer is a single platform supporting the visualization of medical images in any format—both DICOM and non-DICOM—and imaging reports that can run on any off-the-shelf computer or universal device in any location to support the workflow of any physician, as the enterprise requires. In other words, it makes im-ages available wherever, whenever and to whomever needed. The solution eliminates the need for users to log into a specialized radiology PACS or other de-partmental system to view imaging data, as well as the patchwork of specialized solutions often used to provide image access beyond the department that created the imaging data. Such a viewing solution may replace or coexist with a traditional PACS viewer

Executive Summary:In today’s rapidly evolving healthcare environment, the need for cross-department and cross-enter-prise information sharing is greater than ever before. This is particularly true for diagnostic images. A universal medical image viewer meets this need by enabling viewing of any medical image, imaging report and related patient data anytime and anywhere outside of a PACS environment. At last digital image access is no longer confined to the department that created the data.

However, all universal viewers are not created equal. This whitepaper examines the attributes of a universal viewer, viewing use cases, and the features and functionalities available in the technology today. It provides a valuable guide for medical professionals charged with the task of evaluating viewers and selecting one to meet the medical facility’s needs.

and may be integrated with a vendor neutral archive (VNA) or electronic health record system (EHR).

Not surprisingly, the requirements of a universal viewer for a small hospital are often relatively modest compared to the needs of a large, multi-site institution operating in an expansive imaging environment with digital radiology, cardiology, laboratory, ophthalmology and wound care files, a broad network of consulting clinical specialists and referrers covering a large geographic area. To satisfy all its needs and make the most of its budget, hospitals must truly understand their full

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image distribution requirements before they begin a search for a solution.

ATTRIBUTES OF A UNIVERSAL VIEWERToday, hospitals can easily find a high quality image viewing system that is feature-rich, easy-to-use, ver-satile, secure, and affordable. Some systems actually deliver performance similar to a standard standalone PACS viewer—with all the bells and whistles. But not all viewers are created equal. So a hospital must un-derstand its needs, survey the marketplace and make its choice carefully.

Best of Breed SolutionThe best universal viewing solutions provide a range of advanced functionalities that will enable versatile image communication now and as a hos-pital’s needs expand in the future. These include:

• Zero-footprint browser-based technology to view all standard and less-common DICOM files for every imaging modality.

• Viewing of all standard and non-standard DICOM images from other medical specialties such as cardiology and pathology.

• Display of additional image formats, such as jpeg, tiff, avi, mpeg, often used for laboratory, ophthalmology and other images.

• Viewing textual reports.

• Support for the IHE XDS profile.

• Server- side image processing.

• Support of a full range of hard- ware and platforms, including PC and MAC, as well as Android, BlackBerry, iOS, and Windows.

• Support for all standard Web browsers, including legacy technology.

• Streaming technology to make the most of available bandwidth.

• API for easy integration in other clinical systems.

• Scalability to accommodate a large user base.

UNIVERSAL VIEWING USE CASESA universal viewer enables radiologists and clinicians to access patient images and reports when needed, realizing faster diagnoses, therapy decisions and enhanced patient care. The technology supports a variety of other important use cases. These include:

• Image viewing across the enterprise outside of a PACS solution through a VNA or other enter-prise-class archive.

• Image-enabling an electronic medical record (EHR) solution.

• Cross-enterprise image sharing for collaboration and second opinions.

• Cross-enterprise image sharing for trauma transfers and other emergency cases, enabling decision-making on a case before the patient is transferred.

• Referring physician image access, typically through a physician web portal.

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• Image viewing across a health information exchange (HIE).

Not every viewer is the best selection for every one of these use cases, and technology choices must be predicated on every site’s needs. Hos-pitals should be sure to identify a system robust enough to meet all their demands today, with an eye towards future needs. But remember, users can also make the most of their budgets by mak-ing wise choices and not paying for features they will never need.

BENEFITS OF A UNIVERSAL VIEWERBy providing immediate access to all physicians who need images, a universal viewer can signifi-cantly enhance patient care by speeding diag-nosis and increasing treatment efficiency and precision. These viewers also provide conve-nience and efficiency to all staff involved in using or facilitating access to images, streamlining hospital processes and procedures. They play a large role in enhancing communication with referring physicians.

TECHNOLOGY OVERVIEWToday, most universal viewers are browser-based, employing some form of thin-client or zero-foot-print technology that downloads from a central server or off-site cloud environment, which is part of the system. This enables use on a wide range of devices in multiple locations with minimal or no updates on these devices.

Images to be accessed can be either cached on a universal viewer server or streamed to the serv-er directly from archiving systems like a PACS or a VNA. Users then access the server through a web browser and interact with the application and imaging data remotely—the computing power lies on the server hardware, not the local device. The best viewers do not download images to the device, minimizing security concerns. When viewing an image, an authorized user will log into the application with secure authentication proto-cols, find the desired image and continue from there. The device’s connection, whether wired

or wireless, also is an important ingredient in the mix. Secure and fast connections are a must for high performance. However, note that Web-based viewers may use a browser for image display, but can still employ proprietary technology, limiting the usefulness of the images. At times, vendors are less than literal with their descriptions—so buyer beware. Thin Client vs. Zero-FootprintThe early wave of universal viewers was based exclusively on thin-client technology, with most of the viewing applications running from a server. A plug-in or download of various sizes on the view-ing hardware was required. Today, many univer-sal viewers continue as thin client applications. During the past few years, some vendors have progressed to a flavor of zero-footprint technology that still requires installing Adobe Flash software on the device. Few solutions require absolutely no software on the viewing device. One solution that requires no device downloads is Claron’s family of Nil pure zero-footprint viewers.

From an IT perspective, thin client technology can create a complex and difficult to maintain IT environment. IT departments need to support the portions of the viewing solution running on remote devices in what is often an uncontrolled operating environment—an iPhone or tablet, which may be treated casually compared to an in-house viewing

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system. Also, upgrading and maintain-ing the resident portion of the view-ing software across multiple devices controlled by the user may become difficult and frustrating.

Therefore, a zero-footprint solution offers tangible advantages over thin client technology. But on the down side, it can demand a compromise on advanced features. The issue, in part, is the ability of the user interface on a local device to control an ap-plication running on a remote server quickly and efficiently to manipulate images as desired. Some vendors, such as Claron Technology, have invested significant efforts in making the most of wireless bandwidth to enhance performance and to inte-grate the most sophisticated viewing functional-ities into their systems. Therefore, the viewers deliver the best of both worlds.

FEATURES AND FUNCTIONALITIESWhether to deploy a thin-client or true zero-foot-print universal viewer is just one decision. Next, technology purchasers must look closely at a viewer’s features and functionalities and consider the following:

Non-Diagnostic and Diagnostic ViewingMost universal viewers support non-diagnostic image viewing only. Few viewers can manage the large data sets involved with diagnostic display. However, some systems, such as Claron’s Nil, do offer both alternatives. Hospitals that need sup-port for full fidelity diagnostic images should care-fully investigate the options offered by the system under consideration.

Image ManipulationWhen looking for a viewer, examine your image manipulation needs carefully, and think ahead into the future. The image viewing toolsets built into universal viewers vary widely. Many offer basic functionalities such as pan, level and zoom, but the selection is smaller when it comes to ad-vanced features such as MIP and volume render-

ing as well as advanced measurement tools such as ellipse, contour, ROI, and Cobb angle. A few viewers, such as Claron Nil, will also sup-port full dynamic cardiology exams with multiple synchronized cine loop and multimodality oncol-ogy fusion. If users want PACS workstation-quality performance, it does exist. So make sure you select the appropriate solution.

Image SharingSome image use cases call for transmission of actual image files to a remote location, instead of simply enabling remote viewing. These cases in-clude trauma transfers and other transfer patients with existing images that need to be added to the patient record. Certain universal viewing systems will support this data transfer in a highly secure fashion – without a VPN. If you need to view im-ages in the scenarios above, look closely at the features each vendor offers.

Ease-of-UseEase-of-use is always desirable. But, what is user friendly to one physician may be extremely limiting to another. Viewers such as Nil offer versions to meet the needs of different user groups. NilShare viewer is designed for referring physicians, while NilRead (currently under FDA review) supports diagnostic viewing and offers more sophisticated features. These include

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hanging protocols and advanced measurements. To streamline use, also look for a consistent workflow across different devices. Well-designed solutions will work consistently and intuitively across multiple devices and take full advantage of platform features, such as gestures on smart-phones and tablets.

Cost-Effective Technology FeaturesIndustry standard web protocols (secure HTTPS) without the need for VPNs and software down-loads such as Flash on client devices keep costs low. Also crucial is the ability for the viewer to run in a virtualized environment without any special GPU acceleration. This will allow hospitals to host the universal solution in their data center or with a cloud provider in an affordable and scalable way.

Security and AuthenticationSince images are not downloaded to individual devices that can be lost or casually used, server-side technology on its own provides a large measure of security. However, in an uncontrolled mobile environment, security and authentica-tion requirements are far more stringent than in a hospital setting. A system leveraging industry standard web protocols like secure HTTPS enhances security while greatly reducing the user’s security management costs.

Support for single sign-on in a hospital’s specific security environment is important. Many institu-tions will find Windows integrated authentication suitable, but those using other authentication methods should look for a universal solution such as Nil that can delegate authentication to support exist-ing methods. Typically this is through an open API to an external system. Also impor-tant is the system’s ability to grant secure temporary access to users without requiring a permanent account to facilitate collaboration with external partners. Lastly universal solu-tions must log into an audit trail for all access and significant operations.

Image Pre-Fetching and StreamingTo speed viewing, images are often pre-fetched and saved to the cloud server based on an antici-pated need. Some systems support sophisticated user-determined pre-fetch rules that automatically access required images. This particularly benefits physicians who must review priors along with cur-rent studies. Additionally, Claron’s Nil can be con-figured to automatically perform pre-fetching during evenings or off hours to minimize network traffic. When anticipating the need for images in advance is not possible, look for a solution that can stream images directly to remote archives. The best solu-tion will support this with no impact on workflow.

Privileges, Roles and GroupsTo enforce security measures and HIPAA regula-tions, some viewers allow users to be catego-rized and granted viewing rights based on these groups. These considerations are extremely important for referring physician communication, trauma transfer, and other collaborative efforts. Nil, for example, provides maximum flexibility and rules-based definition of privileges. It grants administrators a full set of user privileges includ-ing management of the user group function itself. Remember, customization and easy assignment of privileges for roles and user groups can be crucial.

Maximizing Available BandwidthA universal viewer’s adaptability to varying band-widths is a must. Displaying large images from different modalities in various formats (eg. 2D to

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MPR, 3D and fusion) in a pure zero-footprint view-er is a difficult technological challenge, particularly over a wireless network. This calls for technol-ogy optimization based on available bandwidth. Also important is the ability for a browser to work smoothly across a number of different laten-cies—the time it takes for communication between the universal device and the server. Latency increases with the physical distance between the client and server, and can be extremely variable with wireless connectivity. Look for experienced companies with smart-streaming technologies to address the issue. Also attend to the speed and smoothness of the viewing experience. Ideally these should be similar to a desktop system.

ScalabilityIdentifying a system that can support a site’s an-ticipated number of users and image volume is a major consideration. Server configuration plays a key role in this. Servers may be hardware-based or virtual, and high-volume facilities may require several. If so, load-balancing technology will help assure images are available to all users when needed.

In addition, servers are required to interface with the image archives storing the remote viewing data—whether simply a PACS or possibly an enterprise VNA or XDS data source. With Nil, data from all these sources can be federated and streamed in real time or pre-fetched as needed. In these cases, patient consolidation is impor-tant, and sites using an eMPI (Electronic Master Patient Index) to reconcile patient identifiers must make sure their universal solution supports this. If you are planning an ambitious installation or one that will grow in the future, make sure your remote access vendor offers a robust server set up that will meet your needs.

CONCLUSIONA universal medical image viewer is becoming a necessity in today’s healthcare environment with its emphasis on information sharing and abun-dance of multiple mobile devices used in health-care. A wide range of universal viewers are available with significantly different capabilities, from simply providing access to non-diagnostic

access to images beyond a PACS to highly so-phisticated support for diagnostic quality view-ing with a full range of image manipulation tools and the ability to transmit data files in real time. A medical facility should carefully assess its imaging needs beyond the radiology department and the enterprise to determine what features and functionalities it needs in a universal viewer today and in the foreseeable future. It should also carefully examine the capabilities of a full spectrum of such viewers to find the technology that meets its specific needs.

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